Ann LA BERGE (Blackburg, USA)

A 17

THE EARLY NINETEENTH CENTURY FRENCH PUBLIC HEALTH MOVEMENT

I n h is p ionee r a r t i c le pub l i shed in 1948 E r w i n A c k e r k n e c h t su rveyed t h e F r e n c h hygienic l i t e r a t u r e f rom 1815 to 1848 a n d conc luded t h a t t he F r e n c h w e r e the l eade r s in pub l i c h e a l t h in t h e ear ly n i n e t e e n t h c e n t u r y (1). S ince t h a t t i m e a n u m b e r of h i s to r i ans have inves t iga ted va r ious aspec t s of F r e n c h public h e a l t h h i s to ry . Bu t no o n e h a s a d e q u a t e l y desc r ibed a n d ana lyzed t h e ea r ly n i n e t e e n t h c e n t u r y F r e n c h pub l i c h e a l t h m o v e m e n t . The p u r p o s e of th i s p a p e r is t o do j u s t that. I shal l desc r ibe t h e m o v e m e n t , ana lyze i ts l eade r sh ip , o rgan iza t ion a n d goals , a n d d i scuss s o m e of i t s a c h i e v e m e n t s (2).

The ear ly n i n e t e e n t h c e n t u r y F r e n c h pub l i c h e a l t h m o v e m e n t w a s a m o v e m e n t by a g r o u p of phys ic ians , p h a r m a c i s t s - c h e m i s t s , a n d a d m i n i s t r a t o r s to b r i n g a b o u t pub l ic h e a l t h r e f o r m s in F rance , p r i m a r i l y in t h e ci t ies , in o r d e r to l ower m o r t a l i t y a n d m o r b i d i t y r a t e s and to i m p r o v e t h e qua l i ty of life. T h e m o v e m e n t c lu s t e r ed a r o u n d a n d w a s p r o p a g a t e d by the Pa r i s h e a l t h counci l a n d t h e socie ty of t h e Annales d'hygiène publique et de médecine légale. N ea r l y all t h e l ead ing hygien is t s w e r e m e m b e r s of t he Par i s h e a l t h counci l o r one of t h e p rov inc ia l h e a l t h counci ls . Mos t of t h e leading hygien is t s w e r e founde r s , ed i to r s , a n d / o r c o n t r i b u t o r s to t h e Annales d'hygiène publique, t h e o r g a n of t h e pub l i c h e a l t h m o v e m e n t . M a n y of t he leading hygien is t s w e r e m e m b e r s of t h e Royal A c a d e m y of Medic ine , t h e Royal Academy of Sciences a n d / o r t h e Academy of Pol i t ical a n d Mora l Sciences . I n t hese a c a d e m i e s a n d in local m e d i c a l societ ies d u r i n g t h e ea r ly n i n e t e e n t h c e n t u r y pub l i c h e a l t h i ssues w e r e d e b a t e d a n d pub l i c h e a l t h r e f o r m s w e r e u rged .

The l ead ing ea r ly n i n e t e e n t h c e n t u r y pub l i c hygien is t s i nc luded : in Pa r i s , t h e phys ic i ans Hal le , Vi l le rmé, Paren t -Duchâ te le t , Esqu i ro l , Marc , K é r a u d r e n , Levy, G u é r a r d , Par i se t , B o u s q u e t , P ior ry , Mêlier ; a n d in t h e p rov inces , F o d é r é in S t r a s ­b o u r g , Thouven in in Lille, M a r c h a n t in B o r d e a u x , P igeo t t e in Troyes , a n d Mon-falcon, Pol in ière , a n d T e r m e in Lyon. Lead ing c h e m i s t s a n d p h a r m a c i s t s i nc luded L a b a r r a q u e , Pel le t ier , D A r c e t , B a r r u e l , Cheval l ier , a n d Gaul t i e r de C laub ry ; o t h e r l ead ing hygien is t s w e r e t h e v e t e r i n a r i a n s H u z a r d j u n i o r a n d senior , t h e s t a t i s t i c i an Beno i s ton de Chateauneuf , a n d t h e a d m i n i s t r a t o r T r é b u c h e t .

To set t he chrono log ica l l imi t s of t he m o v e m e n t , t h e decades f r o m 1820 to 1840 inc luded the m o s t i m p o r t a n t ear ly n i n e t e e n t h c e n t u r y pub l i c h e a l t h even t s a n d d e v e l o p m e n t s : t he founding of t h e Royal A c a d e m y of Médec ine w i t h pub l i c h e a l t h goals in 1820 ; t he pub l i ca t i on of L. R. Vi l le rmés ' s s t a t i s t i ca l w o r k in t h e 1820s ; t h e pub l i ca t i on b e t w e e n 1821 a n d 1836 of all t h e hygien ic w o r k s of A. J . B . Pa ren t -Duchâ te l e t ; t h e founding of t h e Annales d'hygiène publique in 1829 ; t h e cho l e r a ep idemic of 1832-35 a n d t h e beg inn ing of t h e r e f o r m of t h e q u a r a n t i n e s y s t e m ; t h e d e v e l o p m e n t by t h e 1830s of t h e Pa r i s h e a l t h counci l i n t o

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t h e p r e e m i n e n t pub l i c h e a l t h a u t h o r i t y in F r a n c e ; a n d t h e d e v e l o p m e n t of pub l i c hygiene a s a scientif ic d isc ipl ine .

The F r e n c h pub l i c h e a l t h m o v e m e n t w a s a n ind igenous m o v e m e n t . I d e a s of p u b l i c h e a l t h h a d b e e n c u r r e n t in F r a n c e f rom t h e l a s t q u a r t e r of t h e e i g h t e e n t h cen tu ry , exempl i f ied by t h e pub l i c h e a l t h goals a n d ac t iv i t ies of t h e Royal Socie ty of Medic ine a n d the H e a l t h C o m m i t t e e of t h e Na t iona l Cons t i t uen t Assembly , a s Caro l ine H a n n a w a y a n d D o r a We ine r h a v e s h o w n (3). By t h e 1820s t h e F r e n c h h a d a wel l -es tabl i shed t r a d i t i o n of i n t e r e s t in pub l i c h e a l t h d a t i n g b a c k s o m e fifty yea r s .

The F r e n c h pub l i c h e a l t h m o v e m e n t w a s quasi-official. Wi th t h e excep t ion of t he Annales d'hygiène publique, t h e i n s t i t u t i ons t h r o u g h w h i c h t h e hyg ien i s t s w o r k e d , such as t h e h e a l t h counci l s , n a t i o n a l a c a d e m i e s , a n d vacc ine c o m m i s s i o n s w e r e g o v e r n m e n t sponso red . I n add i t ion , m o s t hygien is t s h e l d official pos i t i ons — a t t he hosp i t a l s , in t h e p r i s o n sys t em, o n vacc ine c o m m i s s i o n s , a t t h e m e d i c a l facul t ies a n d profess iona l schools . S o m e of t h e l ead ing hyg ien i s t s he ld admin i s ­t r a t i v e p o s t s in t h e m u n i c i p a l a n d d e p a r t m e n t a l a d m i n i s t r a t i o n s . Serv ing o n t h e h e a l t h counci l s , ho ld ing official p o s t s , p a r t i c i p a t i n g in the g o v e r n m e n t - s p o n s o r e d academies , t h e lead ing pub l i c hygien is t s w e r e m e m b e r s of t h e « E s t a b l i s h m e n t ».

The F r e n c h pub l i c h e a l t h m o v e m e n t w a s a n a t i o n w i d e m o v e m e n t . Though m u c h of t h e l e a d e r s h i p a n d o rgan iza t ion w a s Par i s i an , in m a j o r F r e n c h ci t ies such as N a n t e s , Lille, Lyon, B o r d e a u x , Marsei l le , Troyes , a n d S t r a s b o u r g local hyg ien is t s w o r k e d for a n d advoca t ed pub l i c h e a l t h r e fo rm. Espec ia l ly n o t e w o r t h y w a s the very ac t ive g r o u p of Lyonna i s phys ic ian-hygienis t s (5).

The F r e n c h pub l i c h e a l t h m o v e m e n t w a s in te rd i sc ip l ina ry . T h o u g h a m a j o r i t y of t h e leading hygien is t s w e r e phys ic ians , a s izeable m i n o r i t y w e r e p h a r a m i s t s -chemis t s , a n d i m p o r t a n t c o n t r i b u t i o n s w e r e m a d e b y v e t e r i n a r i a n s , a r ch i t e c t s , eng ineers , a n d a d m i n i s t r a t o r s .

The m e d i c a l p ro fess ion p layed a n i m p o r t a n t ro le in the F r e n c h pub l i c h e a l t h m o v e m e n t . The invo lvement of t h e med ica l p ro fess ion in pub l i c h e a l t h m a t t e r s d a t e d f rom t h e e igh teen th c e n t u r y a n d t h e Royal Socie ty of Medic ine . A l though t h e Royal Socie ty of Medic ine d id n o t speak for t h e m e d i c a l p ro fess ion as a whole , it d id r e p r e s e n t one r e fo rm i s t e l e m e n t of t h e p rofess ion (6). In t h e ea r ly n i n e t e e n t h cen tu ry , before t h e c r ea t ion of h e a t h counci ls , local m e d i c a l societ ies of ten se rved as adv i so ry b o a r d s in pub l i c h e a l t h m a t t e r s . Medica l societ ies w i t h i n t h e facul t ies of med i c ine adv i sed t h e n a t i o n a l g o v e r n m e n t on pub l i c h e a l t h conce rns un t i l t h e found ing of t h e Roya l Academy of Medic ine in 1820 (7). The Royal A c a d e m y of Medic ine w a s f o u n d e d w i t h pub l i c h e a l t h goals a s t h e successor to t h e Royal Socie ty of Medic ine . The four p e r m a n e n t c o m m i s s i o n s of t h e A c a d e m y w e r e pub l i c hea l th - re la ted (8). The Royal Academy of Medic ine se rved as a p r i nc ipa l f o r u m for d i scuss ion a n d d e b a t e a n d also h e l p e d s h a p e n a t i o n a l pol icy on pub l i c h e a l t h m a t t e r s .

T h e t w o l eade r s of t h e pub l i c h e a l t h m o v e m e n t a n d t h e m o s t inf luent ial of t h e pub l i c hygien is t s w e r e Drs . Vi l l e rmé a n d Paren t -Duchâ te le t . N e i t h e r of t h e m ever cons ide red h imsel f t h e l e ade r of t h e m o v e m e n t , however . R a t h e r , l e a d e r s h i p w a s a lways a t t r i b u t e d t o g r o u p s : to t h e Par i s h e a l t h counci l a n d to t h e socie ty of t h e Annales d'hygiène publique. These g r o u p s p r o v i d e d b o t h t h e l e a d e r s h i p a n d o rgan iza t ion of t h e pub l i c h e a l t h m o v e m e n t .

M u c h of t h e act iv i ty of t he m o v e m e n t w a s c h a n n e l e d t h r o u g h t h e Pa r i s hea l th counci l , w h i c h func t ioned as a n adv i so ry b o a r d to t h e p re fec t of pol ice, t h e official in c h a r g e of pub l i c h e a l t h for Pa r i s . I n t h e p rov inces d e p a r t m e n t a l h e a l t h counci l s adv i sed t h e p re fec t s in pub l i c h e a l t h m a t t e r s . N ea r l y all t h e l ead ing pub l i c hygien is t s w e r e m e m b e r s of t h e Pa r i s h e a l t h counci l o r o n e of t h e p ro ­vincia l h e a l t h counci l s (9).

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Lead ing hyg ien i s t s w e r e founde r s , ed i to r s , a n d f r equen t c o n t r i b u t o r s t o t h e Annales d'hygiène publique, f o u n d e d in 1829 a s t h e o r g a n of t h e p u b l i c h e a l t h m o v e m e n t . Hyg ien i s t s p u b l i s h e d n u m e r o u s a r t i c les a n d t r e a t i s e s o n al l a s p e c t s of pub l i c hea l th . M o s t of t h e s e w o r k s a p p e a r e d in o n e f o r m o r a n o t h e r i n t h e Annales. T h e Annales d'hygiène publique w a s t h e m a i n s o u r c e of pub l i c i ty for t h e pub l i c h e a l t h m o v e m e n t a n d gave t h e m o v e m e n t i t s visibi l i ty.

F r e n c h hyg ien i s t s h a d b o t h specific a d m i n i s t r a t i v e a n d legislat ive goals . On t h e local level they a d v o c a t e d a d m i n i s t r a t i v e r e f o r m s s u c h a s h o u s i n g r e g u l a t i o n s , i m p r o v e m e n t of s ewerage s y s t e m s a n d w a t e r suppl ies , a n d fac to ry r egu l a t i ons . On t h e n a t i o n a l level t hey u r g e d legis lat ive r e f o r m s : a n a t i o n a l pub l i c h e a l t h l a w se t t i ng u p a n a t i o n w i d e s y s t e m of h e a l t h counci l s a n d t h e r e f o r m of t h e q u a r a n t i n e s y s t e m . Vi l l e rmé c h a m p i o n e d a chi ld l a b o r l aw a n d a civil r e g i s t r a t i o n ac t . Pa ren t -Duchâ t e l e t u r g e d a n a t i o n a l l a w regu la t ing p r o s t i t u t i o n . These r e f o r m s w e r e closely r e l a t e d to o t h e r goals of t h e pub l i c hyg ien i s t s .

F r e n c h hygien is t s w a n t e d t o convince t h e g o v e r n m e n t t o accep t a n d i m p l e m e n t t h e i r definit ion of pub l i c hea l t h . They conceived of pub l i c h e a l t h ve ry b r o a d l y . Publ ic h e a l t h w a s a l l -encompass ing ; eve ry th ing w a s in i ts d o m a i n . Hyg ien i s t s w a n t e d t o r ep l ace t h e o lde r n a r r o w view of pub l i c hea l th , w h i c h h a d b e e n t h e p r o t e c t i o n of t h e n a t i o n f rom i m p o r t e d ep idemics w i t h th i s n e w e r view. If successful , t h e n t h e q u a r a n t i n e s y s t e m could b e r e f o r m e d a n d t h e g o v e r n m e n t could m o v e i n t o o t h e r publ ic h e a t h a r e a s w h i c h t h e hygien is t s cons ide red cri­t ica l , such a s s a n i t a r y a n d socia l r e f o r m .

The Pa r i s h e a l t h counci l e m b o d i e d th i s n e w e r a p p r o a c h to pub l i c hea l th . I n o r d e r to e x t e n d t h e benefi ts of t h i s i n s t i t u t i o n hygien is t s ca l led for a n a t i o n w i d e s y s t e m of h e a l t h counci l s . They a lso u r g e d t h a t t h e s e counci l s b e inves ted w i t h t h e i r o w n p o w e r so t h a t pub l i c h e a l t h w o u l d b e in t h e h a n d s of p ro fess iona l e x p e r t s , t h e pub l i c hygien is t s , r a t h e r t h a n in the h a n d s of e lec ted o r a p p o i n t e d officials.

I n o r d e r to c la im profess iona l expe r t i s e hyg ien i s t s h a d to h a v e p rofess iona l s t and ing . The re fo re one of t he i r p r i nc ipa l goals w a s t h e e s t a b l i s h m e n t of pub l i c hyg iene as a scientific d isc ip l ine . Hyg ien i s t s s o u g h t t o define a n d de l imi t pub l i c hyg iene a s a d isc ipl ine a n d to app ly w h a t they u n d e r s t o o d as t h e scientific m e t h o d to t h e s t u d y of pub l i c hygiene .

By 1848 hyg ien i s t s h a d ach ieved s o m e of t he i r goals a n d h a d m a d e i m p o r t a n t c o n t r i b u t i o n s t o pub l i c hea l t h . The i r a c h i e v e m e n t s i nc luded t h e t r a n s f o r m a t i o n of t h e Pa r i s h e a l t h counci l i n t o t h e lead ing pub l i c h e a l t h a u t h o r i t y in t h e Wes t b y t h e 1830s ; t h e found ing a n d c o n t i n u e d pub l i c a t i o n of t h e p ro fess iona l j o u r n a l t h e Annales d'hygiène publique ; t h e r e f o r m of t h e q u a r a n t i n e s y s t e m ; t h e q u a r a n ­t i ne s y s t e m ; t h e p a s s a g e of a chi ld l a b o r l aw in 1841 ; t h e p a s s a g e of a l a w in 1848 es t ab l i sh ing a n a t i o n w i d e n e t w o r k of h e a l t h counci l s ; t h e e s t a b l i s h m e n t of t h e scientif ic d isc ipl ine of pub l i c hyg iene ; m a j o r t heo re t i ca l c o n t r i b u t i o n s , a n d n u m e r o u s p r ac t i c a l s a n i t a r y r e f o r m s .

P e r h a p s t h e t w o m o s t i m p o r t a n t c o n t r i b u t i o n s of t h e F r e n c h pub l i c h e a l t h m o v e m e n t w e r e t h e d e v e l o p m e n t of pub l i c hyg iene a s a scientif ic d isc ip l ine a n d t h e h e a l t h counci l mode l . T h e ear ly n i n e t e e n t h c e n t u r y F r e n c h pub l i c hygien is t s e s t ab l i shed t h e disc ipl ine of pub l i c hygiene on a « scient if ic » bas i s . By scientif ic , t hey m e a n t t h e u s e of f i r s t h a n d obse rva t ion , e x p e r i m e n t a t i o n , a n d t h e n u m e r i c a l m e t h o d to inves t iga te a n d solve pub l i c h e a l t h p r o b l e m s . Ref lec t ing t h e u r g e of t h e age t o t u r n every a r e a of social inves t iga t ion i n t o a « sc ience », t h e hyg ien i s t s t r a n s f o r m e d pub l i c hyg iene f rom a n « a r m c h a i r p h i l o s o p h y » i n t o a n e w science w i t h i t s f ounda t ion in s t a t i s t i c s (10). Cen t r a l t o t h e d e v e l o p m e n t of pub l i c hyg iene a s a scientif ic d isc ipl ine w a s t h e Annales d'hygiène publique. I n t h e i r se lec t ion of m a t e r i a l t h e f o u n d e r s a n d e d i t o r s of t h e j o u r n a l se t t h e l imi t s of p u b l i c hyg iene a n d d e m o n s t r a t e d i ts a p p r o p r i a t e me thodo logy .

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T h e in s t i t u t i ona l e m b o d i m e n t of t h e scientif ic d isc ipl ine of pub l i c hyg iene w a s t h e h e a l t h counci l . By t h e 1830s t h e Pa r i s h e a l t h counci l h a d b e c o m e t h e m o d e l for o t h e r h e a l t h counci l s b o t h in F r a n c e a n d a b r o a d . W h a t w a s n e w a b o u t t he Pa r i s counci l w a s n o t t h a t of a n adv i sory b o a r d of hea l t h . These h a d b e e n i n s t i t u t e d in t i m e s of m e d i c a l e m e r g e n c y a t l eas t a s fa r b a c k as the s ix t een th cen tu ry . W h e n t h e e m e r g e n c y w a s over , t he se b o a r d s w e r e d i s b a n d e d . T h e P a r i s h e a l t h counci l w a s a p e r m a n e n t b o a r d of t echn ica l e x p e r t s set u p t o deal w i t h day- today p r o b l e m s involving any a spec t of t he pub l i c hea l th . T h e success of t h e Pa r i s counci l led to t h e e s t a b l i s h m e n t in t h e 1820s a n d 1830s in a n u m b e r of F r e n c h ci t ies of h e a l t h counci l s b a s e d on t h e P a r i s m o d e l . The Pa r i s counci l w a s a lso t h e m o d e l u s e d in 1848 w h e n a n a t i o n a l l aw se t u p a n a t i o n w i d e n e t w o r k of h e a l t h counci l s . I n add i t ion , t he Par i s m o d e l w a s cop ied in the n e w Belgian n a t i o n in t h e mid-1830s w h e n h e a l t h counci l s w e r e e s t a b l i s h e d on a n a t i o n w i d e b a s i s a n d in 1847 w h e n the K i n g d o m of S a r d i n i a i n s t i t u t e d a s y s t e m of h e a l t h counc i l s .

I n the final analys is , t h e ex t en t a n d type of hygien ic l i t e r a t u r e , t h e n u m e r o u s act iv i t ies of t h e pub l i c hygien is t s , t h e pub l i c h e a l t h i n s t i t u t i ons , t h e p ro fes s iona l j o u r n a l of t h e m o v e m e n t , t h e theo re t i ca l a n d p r ac t i c a l c o n t r i b u t i o n s all a t t e s t t o F r e n c h l e a d e r s h i p in pub l i c h e a l t h in t h e decades b e t w e e n 1820 a n d 1840. I n t e r m s of a c t u a l pub l i c h e a l t h r e f o r m s , b o t h a d m i n i s t r a t i v e a n d legislat ive, s ignif icant a c c o m p l i s h m e n t s w e r e m a d e . B u t i t s e e m s to m e t h a t t h e g r e a t e s t c o n t r i b u t i o n of t he ear ly n i n e t e e n t h c e n t u r y F r e n c h pub l i c hyg ien i s t s w a s theore t i ca l . They e s t ab l i shed a n e w definit ion of pub l i c h e a l t h for t h e age a n d founded t h e m o d e r n disc ipl ine of pub l i c hygiene .

N O T E S

(1) Erwin Ackerknecht , « Hygiene in France, 1815 - 1848, » Bull. Hist. Med., 1948, 22 : 117 - 155. (2) The principal sources for the conc lus ions I have reached here are the Annales d'hygiène

publique, 1829 - I860, the pr inted and manuscr ip t reports of the Paris hea l th counci l and all the provincial heal th counc i l s , the hygienic wri t ings of major and minor hygienis t s , p u b l i s h e d reports and m i n u t e s of the relevant academies , archival sources pertaining t o publ ic heal th in the National Archives , Paris, and in the departmental archives where hea l th counci l s w e r e located, and the munic ipa l archives of Lyon.

(3) Caroline Hannaway , « The Soc ié té Royale de Médecine and Ep idemics in the Ancien Reg ime , » Bull. Hist. Med., 1972, 45 : 257 - 273 ; Dora B. Weiner, « Le Droit de l ' H o m m e à la Santé : une bel le idée devant l 'Assemblée const i tuante : 1790 - 1791, » Clio Medica, 1970, 5 : 208 - 223.

(4) Terme and Prunel le w e r e mayors of Lyon ; Trébuchet w a s head of the sanitary office at the Prefecture of Pol ice in Paris .

(5) Terme, Prunel le , Sainte-Marie, Bottex , Monfalcon, Pol inière, Pointe. (6) Hannaway, « The Soc ié té Royale de Médec ine . » (7) S u c h as the Soc ié té de l 'Ecole de Médec ine of the Paris Faculty. (8) The permanent c o m m i s s i o n s w e r e : the vaccine c o m m i s s i o n , the ep idemic c o m m i s s i o n , the

mineral w a t e r c o m m i s s i o n , and the secret remedy c o m m i s s i o n . (9) Dora Weiner, « Public Hea l th Under N a p o l e o n : the Consei l de Salubri té de Paris , 1802 - 1815, »

Clio Medica, 1974, 9 : 271 - 284 ; Ann Fowler La Berge , « The Paris Heal th Council , 1802 - 1848, » Bull. Hist. Med., 1975, 49 : 339 - 352.

(10) Parent-Duchâtelet spoke of hygienic theories as be ing cons truc ted « dans le s i l ence du cabinet . » I have used the t erm « armchair ph i losophy » to descr ibe Parent's att i tude. See Parent-Duchâtelet , « Mémoire sur les débardeurs de la vi l le de Paris , » Hygiène publique, 2 vo l s . (Paris : Bai l l ière , 1836), II : 640.

(11) Ambroise Tardieu, « Introduct ion » to the second edit ion of Dictionnaire d'hygiène publique et de salubrité, 4 vo l s . (Paris : Bai l l ière , 1862), I : VII - X .

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